Article

Thrombolysis after initially unsuccessful cardiopulmonary resuscitation in presumed pulmonary embolism

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American Journal of Emergency Medicine

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Thrombolysis after initially unsuccessful cardiopulmonary resuscitation in presumed pulmonary embolism

Abstract

The life-saving administration of thrombolytic therapy after initially unsuccessful cardiopulmonary resuscitation (CPR) in 7 patients with presumed pulmonary embolism (PE) was reported. Seven patients who had cardiac arrest were admitted to our emergency department. The clinical diagnosis of all these patients was highly suspected with PE; therefore, 50 mg recombinant tissue plasminogen activator with 50-mL dilution was administered in a 15-minute period after initially unsuccessful CPR. Of 7 patients, 5 (71.4%) achieved return of spontaneous circulation after CPR and thrombolytic therapy, and 3 (42.9%) of 7 patients were discharged alive through successive treatments. A 90-day follow-up showed that

2 patients were Neurologically intact, and 1 patient was mildly disabled. These results demonstrate that thrombolysis after initially unsuccessful CPR in presumed PE may have beneficial effects.

Pulmonary embolism (PE) has an incidence of approximately 0.1% among the general population and accounts for 2% to 15% of unexpected sudden death, 2% of all cardiac arrest , and 6.5% of noncardiac CA. fulminant PE can cause CA in 41% of cases, with a mortality ranging from 65% to 95% [1].

Fulminant PE can produce CA through multiple mechanisms, most commonly by obstructive shock with severe dysfunction of the right ventricle, and other mechanisms include arrhythmias and vasovagal reflex [2]. Once CA occurs, external chest compression may be effective in fragmenting large emboli and thus re-establishing pulmonary circulation. However, when pulmonary artery is completely obstructed, simple chest compression is difficult to restore spontaneous circulation. Under this circumstance, other measures, such as thrombolysis, emergency thoracotomy, and embolectomy, should be tried. Among these, thrombolysis has attracted much attention because of its easy administration, rapid action, and physiopathologic benefits.

Here, we reported administration of thrombolytic therapy in 7 patients with highly suspected PE after initially unsuccessful cardio- pulmonary resuscitation (CPR) in our emergency department (ED).

These 7 patients with CA were admitted to the ED of Beijing Chaoyang Hospital, which is an university hospital, from February 2013 to December 2013. The initial rhythm of these patients was pulseless electrical activity when arriving at the ED, and the time between occurrence of CA and arrival of ED ranged from 5 to 20 minutes (Table 1). CPR was started immediately according to the recommendations of 2010 CPR guidelines [3].

The initial CPR time ranged from 20 to 45 minutes. During this period, PE was highly suspected based on previous medical histories, symptoms, and laboratory results in these 7 patients (Table 2). Therefore, after obtaining written informed consent

forms from legal relatives, 50 mg recombinant tissue plasminogen activator (Alteplase, Boehringer Ingelheim, Ingelheim am Rhein, Germany) with 50-mL dilution was administered via peripheral intravenous infusion in a 15-minute period during ongoing CPR.

The total CPR time ranged from 28 to 100 minutes. After CPR and thrombolytic therapy, 5 (71.4%) of 7 patients achieved return of spontaneous circulation (ROSC). These patients were admitted into the emergency intensive care unit to receive post-CA therapies. Patient 1 died at 3 days after ROSC because of heart failure. Patient 6 died during the subsequent hospital stay for pulmonary infection. Finally, 3 (42.9%) of 7 patients were discharged alive.

The neurologic outcome was assessed by the Glasgow Outcome Score (GOS) [4]. The 90-day GOS of 3 patients was 5, 5, and 4, respectively, indicating that 2 patients were neurologically intact and 1 patient was moderately disabled (Table 3).

Pulmonary embolism may cause a large number of CA with a high mortality. The high mortality is partly due to the fact that PE is often underestimated [5]. Therefore, clinical suspicion of PE as a cause of CA remains the key in timely treatment. In clinical practice, diagnosis of PE in cases of CA is difficult to establish; under such circumstance, the diagnosis is often a clinical one, mainly based on previous medical histories, symptoms, signs, and auxiliary examinations [6].

In our report, 5 of 7 patients had High-risk factors of PE, and the most suggestive symptoms of PE were dyspnea and syncope. In addition, electrocardiogram showed SIQIIITIII in 2 patients, and echocardiography showed right heart enlargement and pulmonary hypertension in 4 patients. Furthermore, D-dimer levels of these 7 patients were all significantly elevated (Table 2). Taken together, these symptoms and signs should reinforce the clinical suspicion of PE in the presence of CA. On the other hand, 2 patients with ROSC were confirmed to be PE through computed tomography of pulmonary artery and pulmonary radioisotope scanning, whereas another 3 patients with ROSC were highly suspected of PE because of right heart

Table 1

Clinical characteristics of 7 patients

Age (y)

Sex

Time between CA and arrival of ED (min)

Time between start of CPR and

thrombolysis (min)

Total CPR time (min)

ROSC

1 56

Female

15

35

80

Yes

2 40

Female

10

25

42

Yes

3 48

Female

5

20

28

Yes

4 22

Male

20

20

100

No

5 59

Female

20

25

35

Yes

6 85

Male

10

40

60

Yes

7 76

Male

5

40

90

No

0735-6757/(C) 2014

Table 2

Clinical evidences of PE in 7 patients

High-risk factors of PE

Symptoms

D-dimer

(mg/L)

Other manifestations of PE

Diagnostic evidence of PE

1 None

Chest tightness for 1 d

5.92

Right heart enlargement and pulmonary

Suspected diagnosis: right heart enlargement

hypertension on echocardiography

and pulmonary hypertension were improved

on echocardiography after thrombolysis

2 None

Recurrent syncope for

1 mo

11.85

SIQIIITIII on electrocardiogram of

other hospital

Confirmed diagnosis: pulmonary radioisotope

scanning showed left PE

3 8 d after surgery of venous

thrombus of Left lower extremity

Sudden dyspnea for 1 h

8.96

SIQIIITIII on electrocardiogram of

other hospital

Confirmed diagnosis: CT of pulmonary artery

showed right PE

4 Pulmonary cancer

Dyspnea for 1 mo

2.75

Suspected tumor embolus of pulmonary

Suspected diagnosis: suspected tumor embolus

artery on pulmonary enhanced CT of

of pulmonary artery on pulmonary enhanced CT

other hospital

of other hospital

5 28 d after surgery of

Dyspnea and chest

4.62

Right heart enlargement and pulmonary

Suspected diagnosis: right heart enlargement

lumbar vertebrae

pain for 7 d

hypertension on echocardiography

and pulmonary hypertension were improved

on echocardiography after thrombolysis

6 Lying on bed for 15 d because

Dyspnea for 1 d

3.95

Right heart enlargement and pulmonary

Suspected diagnosis: right heart enlargement

of fracture of right lower extremity

hypertension on echocardiography

and pulmonary hypertension were improved

on echocardiography after thrombolysis

7 Varicosity of left lower extremity

Syncope for 1 d

7.58

Right heart enlargement and pulmonary

Suspected diagnosis: right heart enlargement

hypertension on echocardiography

and pulmonary hypertension on echocardiography

Abbreviation: CT, computed tomography.

enlargement and pulmonary hypertension were significantly im- proved on echocardiography after thrombolysis (Table 2).

The first use of thrombolysis during CPR in a patient with PE was reported by Renkes-Hegendorfer and Hermann in 1974 [7]. Since then, more than 100 cases of successful administration of thrombol- ysis in patients with confirmed or suspected PE during CPR have been published, when the thrombolysis was almost always used as a last resort [8]. Besides case series, clinical studies have also confirmed the effectiveness of thrombolysis [9,10]. However, currently, the use of thrombolysis in CA caused by PE has not been supported by prospective, randomized, controlled trials.

Although thrombolysis is effective in saving patients with PE, many scientific societies have advised against its use during CPR, based on the opinion that ongoing CPR is a contraindication to Thrombolytic treatment due to the risk of causing lethal Bleeding complications. However, Janata et al [11] compared 36 patients who received thrombolysis with 30 patients without thrombolysis with CA due to PE in a retrospective study and concluded that although severe bleeding complications tend to occur more frequently in patients undergoing thrombolysis, the benefit of this treatment might outweigh the risk of bleeding.

In our report, 50 mg recombinant tissue plasminogen activator with 50-mL dilution was administered via peripheral intravenous infusion in a 15-minute period during ongoing CPR. Of 7 patients, 5 (71.4%) achieved ROSC after CPR and thrombolytic therapy, and 3 (42.9%) of 7 patients were discharged alive through successive treatments. A 90-day follow-up found that 2 patients were neurolog- ically intact and 1 patient was moderately disabled. Furthermore, there were no records of major bleeding complications in 5 patients

Table 3

Prognosis of 5 patients with ROSC

with ROSC. These results demonstrate that thrombolysis is effective and safe in saving patients with CA caused by PE.

In conclusion, outcome of CA depends largely on the existence of potential Reversible causes. Proven or highly suspected thrombotic etiology is an indication for thrombolysis. In this extreme situation, use of thrombolysis should be strongly considered.

Qin Yin, MD Xiao Li, MD Chunsheng Li, MD

Emergency Department of Beijing Chaoyang Hospital Capital Medical University, Beijing, China E-mail address: lcscyyy@163.com

http://dx.doi.org/10.1016/j.ajem.2014.06.031

References

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    Time between ROSC and occurrence of

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    Time between

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    Kurkciyan I, Meron G, Sterz F, Janata K, Domanovits H, Holzer M, et al. Pulmonary embolism as cause of cardiac arrest. Presentation and outcome. Arch Intern Med 2000;160:1529-35.

  9. 36 No No 1
  10. 12 24 Yes 4
  11. 4 24 Yes 5

    5 10 24 Yes 5

    6 No No No 1

    Abbreviation: GCS: Glasgow Coma Score.

    Er F, Nia AM, Gassanov N, Caglayan E, Erdmann E, Hoppe UC. Impact of rescue- thrombolysis during cardiopulmonary resuscitation in patients with pulmonary embolism. PLoS ONE 2009;4:e8323.

  12. Janata K, Holzer M, Kurkciyan I, Losert H, Riedmuller E, Pikula B, et al. Major bleeding complications in cardiopulmonary resuscitation–the place of thrombo- lytic therapy in cardiac arrest due to massive pulmonary embolism. Resuscitation 2003;57:49-55.

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